Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Saturday, January 26, 2008

Years ago when I was young I was a bartender in a cool place. I was also a bouncer who got by on my height and weight alone as I have no training in that area. I basically do the same thing now. The pay is better, but my customers are the same.

I was at a local chain restaurant tonight eating some wings and drinking coffee and diet coke. Next to me plopped down a tattooed "townie", about 34 years old, with a very ugly woman that I assumed was his mother. She was not.

He turned to me (I had my scrubs on) and said, "Yeah man, I used to be an EMT and the shit you guys see... whew, it still gives me nightmares." Okay, reasonable. The he ordered, "Hey man, get us a few drinks, we've got places to go and people to do, huhuhuh!"

The ugly woman sidled up close to him and placed her beefy hand on his inner thigh. I threw up in my mouth a little bit.

The patient will be here in a few hours. He is on his way out with his lady friend to paint our very small town shades of red, and will, since he's an annoying little fuck, get on the wrong end of a fist or a pipe a knife or gun. I fully expect to see him in a few hours with a messed up face and much drunker.

The only difference here is that he will have paid for his drinks. He will not pay for his hospital bill.

An ugly older woman with beefy man hands and an tattooed skinny "annoying little fuck" wearing his wife beater tank, both of them missing a tooth or two (it's my visual), I bet they get drunk and breed.You, at bouncer height and weight, hmmm........

We use scribes in my ER. They are pre-med students that follow us around and do all of the f**king paperwork so that we can just see the patients.

They learn a lot and it makes us more efficient. So, it's a win-win. I'll come back to the scribes in a moment.........

Last night, I was telling one of the nurses about a TV show I saw about Llamas. The alpha male llama will sneak up on the other males and bite their testicles off to prevent challenges to his dominance. So, people who raise llamas hire vets to cut out these "biting teeth".

So, back to the scribes. I was working with a new scribe who is from India. He overheard parts of the story and he emphatically began to argue that my story was "not possible". He was getting very agitated as he defended these stupid creatures.

Once we finally settled the confusion, I learned that he had never heard of llamas, and he, being a Buddist, thought I was talking about the Dali Lama.

Us ignorant Americans and our antiquated ideas about the Dali Lama biting off the testicles of all challengers to his breeding rights!!!

Anyway, a better tooth story than the tired old one about Southerners and their tooth to tattoo ratio.

One of my pre-med acquaintances said to me, "Em, you should come with me to shadow the ER docs!" She thinks she's a badass because she gets to wear scrubs. I think she's a moron because she wears the scrubs to class.

85 do U remember my story about my OB rotation as a student? For the rest of you..The 1 quote I remember coming from one of my OB resident/teachers was "OF, remember for every pig there is a pig fucker"..Still cracks me up when I remember it...

Well;I guess "twit's" like company. Who says he was "obviously" going to the hospital? Come now we have all seen people who are OBVIOUSLY coming off of shifts at the hospital in public. Can you say C-Diff or MRSA (among other things)? We don't need no "stinkin" infection control man. Or do you "twits" have some magical sensor coming out of your ass in the ER?

Congratulations to this anon! You have been promoted from annoying twit to complete dumbass!

You think changing scrubs will decrease the MRSA and C-Diff ("among other things"....boy that's specific)? You watch too much TV.

I wasn't aware of a massive C-Diff outbreak in the community. Every case I have seen was either a nursing home patient or a person recently treated with antibiotics. I haven't seen any change in the M.O. of C-Diff. Sure, it's more common, but the elderly population is more numerous and antibiotics are more prevalent and potent.

As for MRSA, it's been out there for almost 10 years! The media has recently decided to focus on it (for whatever reason), so every gullible retard like you thinks is's a new big deal. And by the way, the MRSA strains that are in the community have been traced to a DNA mutation in the regular old COMMUNITY Staph Aureus. It's NOT the same strain that we dealt with from nursing homes for the last 20 years (or more). That means that the epidemic wasn't started by someone's scrubs at the end of a shift.

In some studies, MRSA has been shown to live outside of the host for up to 24 hours. It's everywhere dude (I use the dude title since anonomi are asexual, and women aren't usually this stupid).

I see MRSA every day in the ED. Often I see 3 or 4 cases a day (we call our minor care area the "Pus Palace"). I repeatedly hear the same thing: "How did I get this, I haven't been near anyone who has it". I have NEVER heard (of the hundreds and hundreds of cases I've treated) "There was this guy in scrubs and I touched him".

Where is the reservoir for MRSA? It's the nasal ala (that's the entrance to the nose). Changing scrubs wouldn't affect this.

Every hospital employee could shower with Hibiclens before leaving the hospital....and change into street clothes. But I submit that this wouldn't change community MRSA, C. Diff, or "other things" one bit.

I WEAR scrubs every working day, and I've had ONE abscess in the last 20 years. If scrubs were the cause, I'd think (by logic and rational thought) that I'd have them all of the time...as would my partners, nurses, scribes, techs, etc.

Please go to nick.com or cartoonnetwork.com and find a blog that you're smart enough to post on.

Boy you guys really are morons.Do you EVER see patient's outside the ER? Have you actually EVER managed patients with MRSA and C-diff? Seeing them in the ER is NOT MANAGING THEM. Carting them to the hospital Ms EMT is NOT managing them. Yes, thank you for the statement of the obvious, historically MRSA is two different entities (the community acquired being sensitive to bactrim and other oral agents). HOWEVER, more recently the more resistent strain is being seen without clear hospital association. Where did it come from... your ass? The same is also true for C-diff. Look it up "dumbasses". Yes we test for MRSA in the nasal passages because of ease of swabing and it is most commonly colonized at that site. But hello dipshit S aureus is a very common SKIN BACTERIA. It "lives in the "nasal ala". Jeez where the hell did you train. Bangladesh? Following your(lack of) reasoning we shouldn't even gown up in the hospital. The difference between me and you is have actually managed these infections until resolved. Seeing a patient in the ER then dumping them off in the hospitalist is not managing these infections. Certainly shipping these patient's in the back of an ambulance is not managing these infections. I am not saying you should burn your scrubs before leaving the hosptial. I am saying don't wonder around all over the face of the earth. Basic infection control folks.

PS: No Ms EMT he did not make it clear. Either way I see idiots wondering around in scrubs on a daily basis. Thank God I don't work around such ignorant fools in my hospital. I used to come to your site for a laugh. Your combined ignorance isn't making me laugh anymore. Don't worry I won't be back. You guys I way to ignorant to waste my time on.

It also should not take too much common sense on the part of our esteeemed ER/EMS collegues to realize they only know about a small fraction of the people who indeed do have these infections in the ER and act accordingly.

I couldn't even follow the attempt at reasoning in your post, so I won't try to argue most of the non-sequitur arguments. But I gotta respond to two particularly interesting things you wrote.

First: "more recently the more resistent strain is being seen without clear hospital association. Where did it come from... your ass?" We're talking about scrubs here....and you are talking about a bacteria "without clear hospital association" how is this even remotely logical? And, yes it might have come from my ass...sorry.

Secondly: "But hello dipshit S aureus is a very common SKIN BACTERIA. It "lives in the "nasal ala". Jeez where the hell did you train. Bangladesh?" Again, you're changing the subject from SA to MRSA and back again. I am correct when I state that the RESERVOIR for MRSA is the nasal ala. No, I didn't train in Bangladesh....they can tell the difference between skin and scrubs. Sure, skin swabs on all of us (and scrub swabs too for that matter) will grow Staph Aureus, Methacillin resistant Staph Aureus, and God knows what else. But do YOU take a shower and change your clothes before leaving any patient encounter? Do you go into public after work before you take a shower? If so, you're a hypocrit to your own attempt at reasoning.

I think you suffer from a disease that many consultants have. That is one of selection bias.

If you are seeing MRSA or C.Diff patients that are hospitalized, you're seeing a VERY tiny fraction of the patients we see in the ED with "spider bites" and diarrhea. Very tiny indeed.

In my ER, we DO follow the MRSA patients since no one else will do so. After I & D and maybe some Bactrim, Bactroban, or Clindamycin if indicated, 99% of these people are better. I can't remember the last time I admitted an MRSA patient (no memory jokes...it's just been a while). So, your assertion that us ER folk are sittin' around in our bacteria infested scrubs drinking mint julips and admitting the MRSA patients for you to "manage" is simply idiotic (at my place anyway...and if your ER docs have it THAT good, send me an application). We treat AND manage almost ALL of them. The ones you see are (hopefully) the complex cases.

As to the scrubs issue, about half of my group wear slacks and polo shirts to work, and some even wear ties (dorks). Doesn't seem logical that those clothes would be any less of a fomite than scrubs.

I will concede to you that infection control people teach the clothes, scrubs, gown/glove, and hand washing stuff all day long. From a purely technical perspective, I don't think you're wrong.....from a practical and logical perspective, I think you're nuts.

Come back to our blog for laughs (sadly, there are lots at your expense right now), but get a user name and be responsible for your comments.

Unfortunately ER doc85 you suffer from your own "selection bias". though I agree I see a smaller fraction of simple cellulitis that you do, You see probably only really know about 5% of all diagnosed MRSA patient's in the hospital (and trust me they all don't come in with MRSA, we give it to them). Most are diagnosed AFTER being hospitalized. You know about the ones that tell you and the ones with hospital records. In short you don't really have a clue about the vast majority of MRSA patients. I am not blaming you on that one. There is no way to know until the cultures are back which you may (or may not) hear about. Think about it, suddenly with the diagnosis of MRSA on the floor (or c. diff) the gowns, gloves, masks magically appear. What's the difference between that patient in the ER and the floor otherwise, really nothing besides the knowledge. The spread of MRSA and C-diff in hospitals is obviously been very well documented/published (hence the coverings). I know you know that (the EMT does not apparently). What is not well documented is the emergence of the hospital type resistent MRSA's in the community. Where did it come from (the only known setting presently is hospitals unless you want to blame it on expanded resistence, nobody knows the right answer here). Either way, you don't know about it in the ER. Also I have personally taken care of several C-diff patient without clear association, this scares me more personally. The issue is not just scrubs. It is all work clothing. Don't let your personal invective against me play a role here but think about this. If you don't know about the 90-95% of MRSA patient's diagnosed (that you admit), if all hospital protocols involve covering protection based on very well documented studies showing patient to patient transmission, then doesn't it make a modicum of commen sense not to wander around the planet in your work clothes (whether they be scrubs or dokkers)? Yes we can make arguments about how the majority of the populace is not immunocomprimised etc, etc. But I am here to tell you firsthand hospital type MRSA's are showing up in the community (and yes we can argue epidemiology that no one can yet answer). Heck, I even have a doc associate who aquired MRSA as a resident. It is a little common sense here. I am not saying, burn your dokkers or scubs after work. I am saying after draining pus all day, doesn't it make sense not to wander around in the same clothes? I am not a hypocrite. I don't wander around the planet after work in my clothes or scrubs. They get promptly washed. You are correct that gowns for every patient do not make sense (though if this continues you never know). I guess the difference between you and me is I have seen too many cases of clear patient to patient transmission of both MRSA and C. diff. I have seen cases of hospital type MRSA (and C. diff) that I can't explain. I have a very healthy respect for these infections. Also, again though MRSA can be mos commonly isolated in the nasal passage. It's "reservoir" is anywhere on the human body run of the mill staph is. Don't hang you hat on a nasal swab. ON a personal note I have never, ever heard of ER managing skin infections (or other) after the ER visit. No community health clinic in your city? Lastly I am and (will remain) an anon for one reason...flea (the pediatrician not the insect).

PS: MR. EMT: I am sorry you don't know what you don't know. I am not going to try to condense my 9 years of post graduate education (and 20 years of work experience) into bite-sized morsals for you. Suffice it to say. If you evaluate/transport patients you should know a little more than "shit" about MRSA and C. diff. May I suggest you look it up?

Very cogent post. Thank you. I do not deny that I also have a selection bias towards MRSA. I think we are arguing about apples and oranges. I'm talking about the shit I see all day long, drain, and dismiss. You're talking about much sicker patients...and also iatrogenic infections on patients who are there for something else.

Being a flea shouldn't prevent you from getting a user name and becomming a "known quantity" on the blog (all "anons" are considered FOS until proven otherwise). This blog wasn't intended to be an ER Doc overload. The original goal was to have different specialties represented. Etotheipi is the only non-EM contributer...and his posts always have a different (and usually very unique and hysterical) perspective. Your viewpoint is more than welcome and desired!

I too am a flea at heart having done my first residency in IM, then my "real" residency in EM (neither was in Bangladesh). Somehow, the flea never actually leaves the host. Even though OldFart "dipped" me before EM to rid me of all parasites.

Last eve, I drained 3 community acquired "spider bites" (all consistent with MRSA), packed them, and made an appt for them to return in 2 days for recheck.

However, one of my partners had a patient with a facial abscess/cellulitis that had progressed despite being seen in the ED the day before with I&D, IV Vanco, and p.o. clinda (cx were still pending but Gram stain was + cocci in clusters). She needed to be admitted....so now I remember when the last time we had to admit a (probable) MRSA. I thought about you and chuckled when I heard about the case.

On your personal note: yes we have a community health clinic, but they see diabetics and hypertensives who need meds and followup (frankly, I'd rather them use their limited budget for that and leave the pus to me). They're not set up to deal with MRSA (in fact I occasionally see patients from there after no I&D, who are not getting better on Keflex)! In my last two jobs (9 years) the ER was where we followed MRSA. Very few of these patients have any insurance (more selection bias).

On another personal note, em is a good kid. He's working half of his ass off and studying the other half off. If he has any ass left, he'll be taking care of us one day when we're brought in from the nursing home. He won't be a surgeon...he won't have any asshole left!

I'll promise to wash my scrubs if you'll get a user name and lets change our conversations into something comic and entertaining.

I agree with the bullet in the brain vs. ETT...I once had a 21 year old patient from a wreck...she could only move her thumbs...she layed in a bed for a good year before she got sick one night...aspirated her vomit, hypoxic brain injury...got pneumonia...she sucked on a vent for the rest of her so called life. *sigh*